Gyn Flashcards by Dr. Dohm

Staging Cervical Cancer:
Stage I?
Stage II?
Stage III?

Stage IA1 stromal invasion <=3mm
IA2 invasion >3mm and <=5mm

Stage IB1 lesion limited to the cervix uteri with size measured by maximum tumor diameter
IB1 >5mm and <=2cm
IB2 >2 to <=4cm
IB3 >4cm

IIA Involvement limited to the upper two-thirds of the vagina without parametrial invasion
Stage IIA1 Invasive carcinoma ≤4 cm in greatest dimension
IIA2 Invasive carcinoma >4 cm in greatest dimension

IIB Parametrial invasion

IIIA Carcinoma involves lower third of the vagina, with no extension to the pelvic wall
IIIB Extension to the pelvic wall and/or hydronephrosis or non-functioning kidney

IIIC1 Pelvic lymph node metastasis only
IIIC2 Paraaortic lymph node metastasis

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Workup for Cervical?

History
Initial/urgent concerns:
Vitals, bleeding, transfusion
Symptoms (pelvic/back pain, post-coital bleeding, urinary or anorectal sx c/f fistula)
PMH: prior pap smears, STD Hx, Immunodeficiency (HIV, solid organ transplantation), inflamm bowel disease
Social: Multiple sexual partners (>10) as RF, Smoking, future desired fertility

Physical exam
Nodal exam
Full pelvic exam: Speculum, Bimanual, rectovaginal
assess tumor size, vaginal, parametria & sidewall involvement (RV)
Place fiducial at distal extent of vaginal disease

Cervical biopsy
Nodes generally not biopsied when treating as locally advanced due to primary
Labs – CBC, CMP (*renal function), pregnancy test, consider HIV
Imaging for IB1 and above
Pelvic MRI
PET/CT
Cystoscopy/proctoscopy + biopsy if concern for bladder/rectal invasion
NCCN: Consider EUA, cystoscopy, proctoscopy for stage IB3 or greater

**Before treatment: **
Diverting colostomy if rectal invasion
Nephrostomy tubes if hydronephrosi

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Who can get fertility sparing? Hysterectomy? Who needs pelvic LND or SLNB?

Cervix

1) up to IB2
2) <=4c (IB2 and IIA)
3) Everyone except IA1 no LVSI.

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Types of hysterectomies?

Class I for Stage IA1(no LVI) total, extrafascial
Removes uterus, cervix, small rim of vaginal cuff.

Class II for Stage IA1 (+LVI/Stage IA2) modified radical
Uterus, cervix, 1-2 cm vag cuff, resect parametrial/paracervical tissue medial to ureters

Class III for Stage IB1+: “Radical”
Resect parametrial tissue to pelvic sidewall and upper 1/3-1/2 of vagina
Should be OPEN (improved OS vs min invasive)

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SEDLIS criteria

Adj RT in cervical?

Presence of any two out of three intermediate risk factors:
LVSI (positive).
Deep stromal invasion (outer 1/3 of cervical stroma).
Large tumor size (commonly ≥4 cm, though thresholds like ≥2 cm are sometimes considered).

45Gy IMRT to reduce LRR 30% to 15%.

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PETERS Criteria

+LN, +margin, +parametria

45Gy+Cis (40mg/m2) increase OS 71% to 81%.

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When would you give brachy post-op in cervical cancer? What reigmen?

NCCN: pos/close (<5mm) margin

Adjuvant EBRT 45 Gy using IMRT, + HDR 6 Gy x 3 to surface (NCCN)

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In cervical cancer what is the pelvic LN involvment riks? PA LN involvment risk? 5 yr OS?

1) Pelvic LN risk is stage x15ish
2) Stage x 10ish
3) 100-Pelvic LN risk %

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Describe volumes for intact cervix?

CTV_1: GTV, cervix, entire uterus
CTV_2: Parametria, superior vagina (2cm below more inferior extent)
CTRV_3: Common, and internal/external iliac, obturator, and presacral nodes (7mm brush)

PTV expansions: 15mm for CTV1, 10mm for CTV2, 7mm for CTV3. Or just use bladder full and empty ITV and 7mm for everything.

*if common iliac or PA node involved field to renal vein or 2cm above disease.

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Gyn Pelvic Constraints for:
1) Rectum
2) Bladder
3) Bowel Bag
4) Duodenum
5) Femoral Head
6) Kidney
7) Spinal Cord
8) Bone Marrow

1) Rectum: V45<50%
2) Bladder: V45<50%
3) Bowel Bag: V40<30%
4) Duodenum: V55<15cc
5) Femoral Head: V30<15%, dmax 115%
6) Kidney: Mean <15Gy
7) Spinal Cord: Dmax <48Gy
8) Bone Marrow: V20<75%, V10<90%
9) Ovaries: <5Gy

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What is point A and B?

What is Point A?
Along the tandem 2 cm superior to the flange and 2 cm lateral
Approximates parametria and ~ where the uterine artery/ureter cross

What is Point B?
Along midline 2 cm superior to the flange/cervical os and 5 cm lateral
Approximates pelvic sidewall/obturator nodes
1/3rd – ¼ of Pt A dose

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Brachy OAR contraints for Gyn?

Bladder: D2cc <90
Rectum, Sigmoid, Bowel, Recto-vaginal point: D2cc <75cc

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Acute and late toxicity for Gyn RT?

Acute: fatigue, diarrhea, dysuria, urinary frequency, skin irritation, hemorrhoid irritation
Late: vaginal atrophy/stenosis, sexual dysfunction, menopause, alteration in bowel/bladder fxn
* Severe late: recto-sigmoid stenosis, fistula, bleeding (rectum/bladder), pelvic insufficiency fracture (10-15%), second malignancy
* Risk of late G3+ severe toxicity < 10% (most < 5%)

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Walk through FIGO staging for endometrial cancer (2009)

IA: < 1/2 MM
IB >=1/2 MM

II invades cervix but not beyond uterus (does NOT Include endocervical glandular tissue)

IIIA serosa or adenixa
IIIB vaginal involvment or parametrial involvment

IIIC1 regional node mets
IIIC2 PA nodes

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What the molecular subgroups in endometrial cancer? How might it change managment per ASTRO but not yet used by NCCN?

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PORTEC-1 and GOG-99 HIR?

High int (GOG): age ≥70 w/ 1 RF; age 50-69 w/ 2 RFs; or age 18-49 w/ 3 RFs (RF=deep 1/3rd MMI, G2-3, LVI)

High int (PORTEC): 2 of 3 RFs (age > 60, MMI > 50%, G3)

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Walk me through VBT. When do you add it to EBRT?

6-8 wks post-op (12 wks max)
Perform pelvic examination to ensure the cuff is healed
Radio-opaque seeds are placed at the top of the vaginal cuff at 9:00 and 3:00
Place the largest diameter cylinder that can comfortably fit (2.5-3.5cm)
Ensure snug fit and securement
CT simulation, planning:
Target upper 3 – 5 cm for endometrioid
Target upper 2/3 for type II histology, extensive LVSI, vaginal involvement, +SM
Daily imaging to verify placement before treatment

7 Gy x 3 Fx prescribed to 5 mm (more fibrosis)

*Add after EBRT if stage II (cervical involvment): 6Gy x 2-3 to surface.

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RT tx recs for stage I-II endometrial?

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How do you treat stage I-II HR histologies (clear cell, serous, carcinosarcoma, dediff or undiff carcinoma.

Stage IA VBT+chemo, Stage IB/II chemo+EBRT

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5yr OS for endometrial adeno?

St I 90% +
St II 80-90%
St III 70-80% (lower for HR histology, p53 mut)

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How do you treat inoperable endometrial cancer? RT dose and goal EQD2?

Definitive RT: WPRT + brachy as standard
WPRT: 45 Gy
Intracavity HDR brachytherapy
Tandem + vaginal cylinder
5Gy x 5 to CTV = uterine serosa, cervix, upper 1-2cm vagina
Goal EQD2 to GTV: 80-90Gy
Goal EQD2 to CTV D90: 65-75Gy

If stage I grade 1-2 with superficial or minimal myometrial invasion on MRI
Brachytherapy alone
7.3 Gy x 5 to CTV = uterine serosa, cervix, upper 1-2cm vagina
Goal EQD2 to GTV: 80-90 Gy
Goal EQD2 to CTV D90: 48-62.5 Gy

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How do you treat vaginal cuff recurrence for endometrial cancer?

If no prior XRT:
WPRT: 45Gy
Vaginal cylinder (<5mm thickness) or interstitial brachytherapy boost (>5mm)
Many use Syed template (if you are not familiar with this, say refer to a center with IS brachy experience
5Gy x5 to cover lesion
HR-CTV: GTV-residual + any thickening/irregular mucosa w/in original tumor extent
Goal EQD2 ~80 Gy. Consider lower ~70 Gy lower vagina (due to tolerance)

If prior RT, surgical exploration and/or systemic therapy. If previous EBRT then brachytherapy +/- systemic therapy.

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FIGO staging for Vulvar Cancer?

IA Tumor <=2cm and stromal invasion <=1mm
IB Tumor >2cm or stromal invasion >1mm

II Extension to lower 1/3 of urethra, vagina, anus (N0)

IIIA Tumor size extension to upper 2/3 of the urethra, vagina, bladder mucosa, rectal mucosa, or regional LN mets <=5mm.

IIIB LN mets >5mm
IIIC LN mets with ECE

IVA Disease fixed to pelvic bone, ulcerated regional LNs
IVB Distant mets

*Regional = inguinal & femoral. Pelvic nodes = DM

Which vulvar patients can get SLNBx? Who need bilateral nodes evaluated?

Criteria for SLNbx in lieu of ILND:
* Tumor < 4 cm
* cN0
* No prior vulvar surgery which may affect lymphatic drainage

Address bilateral nodes for:
Tumor < 2 cm from vulvar midline, > 4 cm, or clinically positive node (biopsy confirmed)

Indications for PORT to primary in Vulvar:

1) +/close SM (<8mm) 2) LVSI 3) Depth >5mm 4) Tumor >4cm 5) Spray/diffuse histology

PORT to nodes in vular? What do you treat?

Any LN+ (> 2 LN+ or ENE: cat 1) If groin is positive, treat the pelvis

Describe SIM for Vulvar.

Supine Frog-leg Vak Lock bag Full and empty bladder for ITV if treating for locally advanced case w/ involvement of vagina, urethra, anus. Treat full bladder. Oral/IV contrast Wire surgical scar / post-op bed Place fiducial on proximal extent of any vaginal involvement BB at anus and urethra to aid in planning Bubble wrap groin if pannus or skin fold Bolus tumor bed if frog-leg, if no auto-bolus Only bolus skin over nodes if skin is involved or ECE

In vulvar if ≥2 LNs pathologically positive what do you cover with RT? What if clinically ≥1 LN+?

The bilateral inguinal and pelvic lymphatic regions are typically included in the radiotherapy CTV in both these scenerios.

What is the RT dose and volume paradigm for definitive vulvar cancer?

Definitive Vulva +chemo if N+ (40mg/m2) unless old and frail: Pelvic lymph nodes (common, internal, external, and obturator nodes): 4500 cGy in 25 fx. Entire vulva: 4500 cGy in 25 fx. Bilateral Inguinal node basin: 5000 cGy in 25 fx. Primary vulvar tumor: 5000 cGy in 25 fx. Involved inguinal nodes: 5750 cGy to 6000 cGy in 25 fx. Following this, a sequential boost to the primary tumor was given of 1600 cGy in 8 fx, totaling 6600 cGy in 33 fx to the primary vulvar tumor

Treatment paradigm for post-op RT for vulvar?

CTV primary: entire operative bed. At least 2 cm beyond close/positive margins. Gross primary vulva disease = 60–70 Gy Primary surgical bed (postoperative, negative margins) = 45–50 Gy Primary surgical bed (postoperative close or positive margins) = 54–60 Gy Clinically and/or radiographically uninvolved inguinofemoral LNs = 45–50 Gy Inguinofemoral LNs (positive, no ECE or gross residual disease) = 50–55 Gy Inguinofemoral LNs (ECE) = 54–64 Gy LNs (gross residual or unresectable disease) = 60–70 Gy

Vulvar Anorectum-PTV and Femoral Head dose constraints?

Anorectum-PTV V40<80% Dmax < 65 Gy Femoral head: V45 < 50% and Dmax < 55

For an inguinal node dissection on vulvar cancer how many nodes should be evaluated?

>=12 LNs, if less than that are evaluated then you should do RT to that side.

Expected overall survival for Vulvar cancer?

Stage I: 90% Stage II: 70% Stage III: 50% Stage IV: 20%

Vaginal Cancer Staging?

Vaginal Cancer Brachy Boost?

Re-staging MRI and exam ~2 wks. If <0.5cm then intracavity. If >0.5cm then interstitial EQD2~75-80Gy upper EQD2 ~70Gy distal

1) Cervical cancer stage with 4cm proximal vagina involvment? 2) 2cm limited to cervix? 3) Parametrial involvment? 4) 5cm lower vaginal involvment? 5) Pelvic sidewall involvment?

1) IIA1 2) IB1 3) IIB 4) IIIA 5) IIIB

Describe vulvar contouring and doses simply?

Everything gets 45 Gy; entire vulva and node (common, iliacs, obturators, inguinals) Sequential boost: 50Gy to involved inguinals (54 ECE) 60Gy to gross nodes 66Gy in primary vulvar.

Who can get cone biopsy? Trachelectomy?

Cone: IA1, IA2 Trachelectomy: IA1 w LVSI, IA2, IB1, and select IB2 *add LN eval or dissection for all but IA1 no LVSI

Post-op cervical constraints?

Bladder: V45Gy<30% Bowel: V40Gy<30% Rectum: V40Gy<80%

Acute and late toxicity of gyn RT?

Acute: Abd cramping, loose stools, diarrhea, dermatitis, cystitis, vaginitis, decreased counts Late: Ovarian failure, infertility, vaginal stenosis, adhesions (rec using vaginal dilator), ureteral strictures (1-3%), intestinal obstruction, fistulas (vesicovaginal or rectovaginal <2%), femoral neck fractures and sacral insufficiency lymphedema

Treatment for radiation proctitis?

Carafate (Sulcralfate) Enema. BID for up to 6 months. Can use proctofaom or steroid enemas.

Follow up s/p chemoRT for cervical cancer?

PET at 3 months then q3 months HP for 2 yrs then q6-12 months to 5 yrs. Counsel on vaginal dilators and smoking cessation.

Tx summary by stage for cervical cancer?

What is Figo Stage IIIA and IIIB for endometrial cancer?

IIIA Tumor involving the serosa and/or adnexa (direct extension or metastasis) IIIB Vaginal involvement (direct extension or metastasis) or parametrial involvement

What definitive RT for medically inoperable endometrial cancer? EQD2 goal?

EBRT 45Gy + HDR 5x5Gy with CTV EQD2 75Gy

5y OS for endometrial cancer?

5y OS Outcomes: Stage IA = 90% Stage IB = 80% Stage II = 70% Stage III = 60% Stage IIIC2 = 40% (PA nodes)

What is stage II for endometrial?

Tumor invading the stromal connective tissue of the cervix but not extending beyond the uterus. Does NOT include endocervical glandular involvement

What surgery is done for endometrial cancer?

TH/BSO with sentinel LN sampling, peritoneal inspection, and omental sample/pelvic washings esp in high risk histologies. *radical hysterectomy only needed for significant cervical involvment.

When can VBT alone be used for stage II endometrial cancer?

Most favorable group only: G1-2, <50%MMI, no LVSI, microscopic cervical invasion and pelvic node dissection.

When can you use T&O alone to treat endometrial cancer? What dose?

Stage 1, G1-2, Inner 1/2 MMI Treat entire uterual/serosa/cervix Dose 7.3x5fx; EQD2 GTV 80-90 and CTV: 48-62.5Gy Anything more than that add EBRT 45Gy + 5Gyx5 Target EQD2 GTV: 80-90, CTV 65-75.

Gyn bladder, rectum, bowel doses, kidney, bone marrow?

Bladder: V45<50% Rectum: V45<50% if postop V40<80% Bowel: V40<30%, duo V55<15cc Bone Marrow: V90<10% and V40<37%.

When do you treat vulvar with adjuvant RT?

primary: depth >5mm, LVSI, tumor thickness >1cm, infiltrative growth pattern (spray or diffuse), mitotic activity >10m/hpf. Adj RT nodes and primary: >+1lN positive, >=2 microscopic LN+

How do you treat vaginal fungal infection?

Topical miconazole Oral Diflucan/Fluconazole: 150mg 1-3 days or 10-14days if refractory

Gyn isodose line constraints for HDR?

450cGy Isodose: bowel, signmoid, vagina 600cGy: bladder

Up to what stage can get a tracheolectomy?

Up to and including IB1.

Sedlis criteria?

Vaginal lubricant name?

Replens

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